When completing a focused skin assessment of a client, the practical nurse (PN) notices erythema on the client's right hip. Which should the PN include in the client's plan of care?
Apply moisturizing cream to the affected area.
Reposition the client every 2 hours.
Lift the client using incontinent pads.
Perform range of motion every 4 hours.
The Correct Answer is B
Rationale:
A. This option is incorrect because applying moisturizing cream alone does not relieve pressure on the affected area. Erythema, especially over a bony prominence like the hip, may indicate early pressure injury, and pressure relief is the priority.
B. This option is correct because repositioning the client at least every 2 hours reduces prolonged pressure on bony prominences, improves circulation, and helps prevent progression of a pressure injury. This is a cornerstone intervention in pressure injury prevention and management.
C. This option is incorrect because lifting a client using incontinent pads can cause friction and shear, increasing the risk of skin breakdown and worsening erythema. Proper lifting devices should be used instead.
D. This option is incorrect because range of motion exercises promote circulation and joint mobility but do not directly relieve continuous pressure on the hip, which is the primary cause of erythema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. This option is incorrect because even when a specimen cup is labeled, placing it in a sealed plastic bag prevents leakage during transport and reduces the risk of contamination. Proper containment is a standard infection control practice.
B. This option is correct because placing the laboratory requisition slip in the outer side pocket of the sealed bag ensures that the specimen is correctly identified without contaminating the paperwork. This method maintains both specimen integrity and accurate documentation, which is essential for laboratory testing.
C. This option is incorrect because while wearing gloves is important during specimen collection, transporting a sealed urine specimen does not require wearing gloves if there is no risk of contact with contaminated surfaces. Gloves may be used, but the key instruction is proper labeling and packaging.
D. This option is incorrect because urine specimens from routine collection are not considered regulated biohazardous waste for disposal. A red biohazard bag is reserved for infectious waste, not standard laboratory specimens. Routine specimens should be transported in a sealed bag to the lab, not discarded in a biohazard bag.
Correct Answer is B
Explanation
Rationale:
A. This option is incorrect because a particulate respirator mask (e.g., N95) is intended for the healthcare worker providing care, not the client during transport. The PN should wear this if entering the client’s room, but it does not prevent the client from spreading airborne droplets while moving.
B. This option is correct because giving the client a surgical mask during transport reduces the risk of airborne transmission of tuberculosis to others in the hospital. Surgical masks on clients containing infectious respiratory droplets are standard practice when moving them outside airborne isolation rooms.
C. This option is incorrect because having a stocked isolation cart outside the room is important for maintaining infection control within the room but does not directly protect others during client transport.
D. This option is incorrect because placing a blood pressure machine in the room is unrelated to infection control or safe transport of a client with tuberculosis.
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